Reproductive History and Pregnancy incidence of Malian and Beninese Female Sex workers before and During Sex Work Practice

Research Article | DOI: https://doi.org/10.31579/2642-9756/075

Reproductive History and Pregnancy incidence of Malian and Beninese Female Sex workers before and During Sex Work Practice

  • Gentiane Perrault Sullivan 1
  • Fernand Aimé Guédou 2
  • Fatoumata Korika Tounkara 1
  • Nana Camara 3
  • Luc Béhanzin 4
  • Marlène Aza-Gnandji 3
  • Bintou Dembele Keita 5
  • Odette Azonnadou 3
  • Ismaila Thera 5
  • Lisa Avery 6
  • Michel Alary 7*
  • 1 Département de médecine sociale et préventive, Université Laval, Québec, Canada.
  • 2 Axe Santé des populations et pratiques optimales en santé, Centre de recherche du Chu de Québec – Université Laval, Québec, Canada
  • 3 Dispensaire IST, Centre de santé communal de Cotonou 1, Cotonou, Bénin
  • 4 École Nationale de Formation des Techniciens Supérieurs en Santé Publique et en Surveillance Épidémiologique, Université de Parakou, Parakou, Bénin
  • 5 ARCAD∕SIDA, Bamako, Mali.
  • 6 Institute for Global Public Health, Dept. Obstetrics, Gynecology and Reproductive Sciences, Max Rady Medical College of Medicine, University of Manitoba, Winnipeg, Canada.
  • 7* Institut national de santé publique, Québec, Canada

*Corresponding Author: Michel Alary, Département de médecine sociale et préventive, Université Laval, Québec, Canada.

Citation: Gentiane Perrault Sullivan, Fernand Aimé Guédou, Fatoumata Korika Tounkara, Luc Béhanzin, Nana Camara. et all (2021) Reproductive History and Pregnancy incidence of Malian and Beninese female sex workers before and During Sex Work Practice. J.Women Health Care and Issues, 4(6); DOI:10.31579/2642-9756/075

Copyright: © 2021 Michel Alary, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 16 June 2021 | Accepted: 26 June 2021 | Published: 30 June 2021

Keywords: sex workers; therapeutic abortion; pregnancy; reproductive health; sub-saharan africa

Abstract

Aim/Background: To reduce maternal mortality (MM), access to family planning and reproductive health care services are key strategies. Access to and use by marginalized populations pose a substantial challenge. The objective of this study was to describe the reproductive history of female sex workers (FSWs) before and during sex work.

Materials and methods: FSWs aged ≥18 years were recruited in Benin, and Mali, to answer a questionnaire during a face-to-face interview. Descriptive analyses were carried out and comparisons made between countries (Pearson chi-square) and between the periods before (BSW) and during sex work (DSW) practice within women in each country (McNemar chi-square). In addition, multiple imputations were used to estimate and compare the incidence rate of pregnancy BSW and DSW calculated with a generalized linear model for count data with a Poisson distribution and a log link.

Results: Mean age was 26 years in Mali (n=322) and 35 years in Benin (n=330). More women had at least one pregnancy BSW compared to DSW in both Mali (62.1%-vs-33.5%) and Benin (91.2%-vs-32.7%). The pregnancies occurring DSW had lower livebirth rates (57.9%-vs-74.7% Mali, 17.6%-vs-60.6% Benin) and ended more often with a therapeutic abortion, DSW compared to BSW, especially in Benin (65.2%-vs-25.6%). The level of complications associated with therapeutic abortion was high, both DSW (23%) and BSW (20%). The incidence rate of pregnancy was about twice lower DSW compared to BSW [incidence rate ratio (IRR): 0.49; 95% confidence interval (95%CI): 0.37-0.66-Mali and IRR: 0.45; 95% CI: 0.32-0.63-Benin].

Conclusion: In both Benin and Mali, FSWs had more pregnancies during the period preceding sex work practice, about twice more than during sex work when considering the differences in incidence rates. Single mothers need to be supported to avoid sex work as a financial solution. On the other hand, the reproductive needs of FSWs need to be acknowledged to reduce maternal mortality within this marginalized population. It is of paramount importance that interventions remain focused on reproductive health and prevent unwanted pregnancies, answer contraceptive needs and provide safe therapeutic abortions.

Abbreviations

BSW: Before sex work 

CI: Confidence interval

DSW: During sex work 

FCFA : Franc des communautés financières africaines

FSW: Female sex workers

HIV: Human immunodeficiency viruses

HPV: Human papillomavirus 

MM: Maternal mortality

IR: Incidence rate 

IRR: Incidence rate ratio

MICE: Multiple imputations by chained equations 

NGO: Non-Governmental Organisation 

Introduction

One of the main action to promote health in the 2030 agenda for sustainable development, proposed by the World Health Organization, is to achieve health equity [1]. Maternal mortality and access to family planning constitute two inequity-related indicators. The global fertility rate in sub-Saharan Africa is 4.6 births per woman during lifetime [2] which is three times the rate in European Union and Canada [3].The maternal mortality rate in this region is also the highest in the world with 542 deaths per 100 000 live births reported in 2017 [4], thus accounting for roughly two thirds of maternal deaths worldwide [4, 5]. In Benin, one in 49 women risks dying due complications of pregnancy and/or childbirth and one in 29 in Mali [4]. To reduce maternal mortality, universal access to family planning and reproductive health care services remains a key strategy globally. 

Marginalized populations are groups that experience discrimination and exclusion because of unequal power relationship across economic, political and cultural dimensions [6]. Because of this exclusion and discrimination, marginalized populations pose a substantial challenge worldwide when it comes to preventing maternal death through use of and access to family planning and reproductive health services [7, 8].

 Sex workers are known to experience discrimination especially in accessing health services [9, 10]. In West Africa, it is estimated that one in 20 women has ever practiced sex work [11] and most African female sex workers (FSWs) are mothers [12, 13].. Moreover, sex work  is associated with many risks that increase pregnancy complications, as well as maternal mortality and morbidity [14]. For example, HIV accounts for 5.5% of the maternal mortality [15] and  among FSWs, HIV prevalence is 12 times higher than in the general population [13]. Unsafe abortion can explain up to 13% of the maternal mortality [16] and lifetime abortion varies between 35 and 65% among FSWs in low and middle income countries [17-20]. 

Despite all these risks and stigma surrounding sex work [21], FSWs have the same rights and desires as women from the general population, regarding pregnancy [22]. Yet, FSWs are underrepresented in fertility-related researches [22] and most of the programmes specifically targeting  FSWs often ignore broader sexual and reproductive care needs and family planning [23].

Meeting the reproductive health needs of this marginalized population is required to prevent maternal mortality [24] and to reach the World Health Organization Sustainable Development Goal that states that by 2030, we need to ensure healthy lives and promote well-being for all at all ages. One of the key priorities is to improve maternal health. To do so, we need to have a better knowledge of the reproductive history of FSWs, not only during their sex work practice, but also before. Most of the researches have been fragmentary in describing their reproductive history (unwanted pregnancy or therapeutic abortion) [25], generally covering their entire lifetime (without differentiation between before sex work practice and during involvement in sex work) [18, 26] or only a small time period [27, 28]. Thus, until now, there is no understanding of the full picture of the reproductive history of FSWs. As a result, many questions remain unanswered and because of this lack of knowledge it is difficult to know which intervention to prioritize and at what moment in a women’s life the intervention should be available...

The objective of this study was to fulfill these knowledge gaps by describing FSWs’ reproductive history before and during sex work in two West African countries (Mali and Benin). To achieve this goal, we first described pregnancy outcomes. Then we characterized the therapeutic abortions. Finally, we calculated and compared the pregnancy incidence rate before and during sex work. 

Materials and Methods

The recruitment for the present study was combined with another one investigating cervical cancer and human papillomavirus (HPV) infection among FSWs [29]. This collaboration was made to avoid soliciting the same population for two studies over a short time period. However, the development of the present study was distinct from the one investigating cervical cancer and HPV. To recruit FSWs, trained peer educators and senior staff from participating non-governmental organisations (NGOs) conducted cervical cancer awareness activities in bars, brothels and hotels, etc. Following these activities, women were referred by peer educators to FSW-friendly clinics Dispensaire IST (DIST) in Cotonou, Benin, and Clinique des Halles run by ARCAD/SIDA, a national NGO, in Bamako, Mali for cervical cancer screening. After participating in the HPV study, they were offered to participate in the study on reproductive history for which they had to complete a questionnaire administered face-to-face. However, FSWs who declined participation in the HPV study or were excluded from it because they were pregnant were also offered to participate in the present study. 330 women were recruited in Cotonou, Benin, between March and June 2017 and 322 in Bamako, Mali, between November 2017 and February 2018.

Inclusion criteria

FSW was defined as any woman who regularly receives money in exchange for sex. To be included in the study, FSWs also needed to have been involved in the sex trade for at least six months in either Cotonou, Benin, or Bamako, Mali, to be aged 18 years or older and to provide written informed consent. All FSWs included in that study are working for money and to our knowledge were not forced to.

Data collection

A quantitative questionnaire developed by the research team was administered during a face-to-face interview by a qualified interviewer. We collected data on reproductive history, pregnancy intention and contraception. Also, a pelvic examination and a urine pregnancy test were carried out by a physician.

All the data regarding sociodemographic characteristics as well as the HIV and pregnancy test results were extracted from the HPV study dataset.

Missing data

Some participants of the study who were excluded from the HPV study because of a positive pregnancy test (n=18 in Mali and n=13 in Benin) did not complete the sociodemographic section of the questionnaire that was only included in the HPV study questionnaire. The sociodemographic data were backtracked for some women in their medical file, but we could not retrieve the missing data for all women. In addition, women included in both studies had some missing values for different variables. Although, the number of women with entirely missing sociodemographic information was low, we used multiple imputation to compensate for these missing data because most of the exclusions from the HPV study were because of pregnancy at the time of enrolment and we wanted to avoid the introduction of a selection bias since pregnancy is the outcome of interest.

Multiple imputation

We wanted to have a complete data set to calculate the incidence rate of pregnancy before and during sex work practice. We used an imputation model with multiple imputations by chained equations (MICE). We decided to use MICE because all the missing values had a non-monotonous pattern and we had to impute different types of variables [30]. We used the distribution of the observed data to estimate the plausible values for the missing data. We included all the variables needed to assess the incidence rate in the imputation model and further added all the variables that were associated either with the variables that had missing values or with the presence of missing values for a given variable [31], as required to obtain valid MICE models. The number of imputations needed was decided based on the rule of thumb [31]. This rule suggests that the number of imputations should at least be equal to the percentage of incomplete cases. The linear variables were not transformed even if they were skewed. We used predictive mean matching to improve the estimation and avoided transforming the relation between the variables in the imputation model [32, 33].

Incidence of pregnancy before and after sex work

The incidence rate was calculated as the total number of pregnancies over the person-time at risk [34]. To calculate the amount of time at risk for pregnancy during sex work practice we used the duration declared by FSWs at the question: for how long have-you been practicing sex work? To calculate the time at risk before sex work practice, we subtracted the duration of sex work from the period of time between age at recruitment and the age at first sex to obtain the amount of person-time at risk before sex work for each woman. To be able to discriminate between pregnancy occurring before and during sex work practice, FSWs were asked specifically how many pregnancies they had before practicing sex work and how many during sex work practice. Furthermore, to validate those results we asked how many pregnancies each woman had during her lifetime and the total was compared with the aggregate for the two periods. Finally, the total number of pregnancies for each period was compared with the summation of the outcomes. When a discrepancy was observed, a verification was made with the research coordinator in each country. 

Statistical analyses

To present the studied population characteristics we used descriptive analyses (frequencies, means values with standard deviations). We also present a comparison between the two countries using Pearson chi-square. 

Furthermore, we used descriptive analyses and paired comparisons (McNemar’s chi-square for discrete variables and paired Student’s t test for continuous variables with normal distribution) in each country, to assess differences in outcomes (pregnancy, therapeutic abortions) according to the period when they occurred (prior to or during sex work practice). For the descriptive analyses, a p-value of 0.05 or less was considered statistically significant.

Thereafter generalized linear model for count data with a Poisson distribution and a log link was used to compare the incidence rate of pregnancy before and during sex work. The log of the duration of the periods before and during sex work was used as offsets in the models. Generalized estimating equations were used to consider the correlation between the periods before and during sex work for a given woman. This analysis was performed with the original as well as the imputed databases. We performed all the analyses using SAS 9.4 (SAS Institute, Cary, NC, USA).

Ethical considerations

Each participant provided a signed informed consent and no nominal information was reported on the questionnaire. The participants received a monetary compensation to cover their transport fees and the possible loss of income due to their participation (5 US dollar in Mali and 2 US dollar in Benin).

The study was approved by the ethics committees of the CHU de Quebec – Université Laval (Quebec City, Canada) and the School of Medicine of Bamako, Mali, as well as by the National Health Research Ethics Committee in Benin. Moreover, all methods were performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki).

Results

Missing data 

Of the 652 FSWs, ten (3.1%) had missing data in Mali for all the sociodemographic variables. In Benin, since we were able to recover some information, seven (2.1%) women had missing information for all sociodemographic variables. We had no missing data for the pregnancy variables (number, outcome and period of occurrence of the pregnancy). For the variables characterising therapeutic abortion, we had five (1.3%) missing data for therapeutic abortion occurring before sex work and four (2.3%) during sex work. We had respectively 16.1% (105/652) of missing data for the number of years before practicing sex work and 5.2% (34/652) for the number of years during sex work practice. For the data set used to calculate incidence rate, 82.2% of the women had no missing information.

Multiple imputations

We did 20 imputations to impute variables for the incidence rate analysis. We used 15 variables in the imputation model. They included the number of pregnancies before and during sex work, the time variables (number of sexually active years while fertile preceding sex work and the number of years as a sex worker), the variables that both predict the number of sexually active years while fertile preceding sex work practice and the number of years as a sex worker and those predicting missing data for each of the latter variables (country, country of origin, religion, education, marital status, number of biological children and HIV status).

Descriptive analyses

Table 1 shows the sociodemographic and sex work characteristics of the participating FSWs. Women in Benin were older (mean age 34.8 vs 25.8 years - p-value <0 xss=removed xss=removed xss=removed xss=removed xss=removed>

Comparison of pregnancy and therapeutic abortion’s prevalence before and during sex work practice

In Mali, during their lifetime, 79.5% of the FSWs had at least one pregnancy and 50.9% more than one (Table 2). 14.9% of the women had at least one therapeutic abortion which represented 18.8% of the women who ever had a pregnancy (data not shown). In Benin, almost all FSWs (95.2%) had at least one pregnancy, 87.9% more than one pregnancy and more than half of them (57.0%) at least one therapeutic abortion (Table 1).

.
.
* According to chi-square comparing all the categories of each variable** The percentages and p-value apply only to FSWs who had sexual relations with a boyfriend during the last 7 days. 209 FSWs in Mali and 190 in Benin had no boyfriend or no sexual relation with a boyfriend during this period.Table 1. Sociodemographic and sex work characteristics of female sex workers in Mali and Benin (n=652)®FCFA (1 US dollars )

By comparing the period during sex work practice and the period preceding, we saw a different picture (Table 2). More women had at least one pregnancy before sex work than they did during sex work in both countries (p-value <0>

Table 2: Comparison of pregnancy and therapeutic abortion’s prevalence between sex work practice and the period preceding (n=652) 

* Using McNemar chi-square tests for the paired comparison of proportions before and during sex work practice and Student’s t-tests for paired observations for the comparison of means before and during sex work practice.Table 2: Comparison of pregnancy and therapeutic abortion’s prevalence between sex work practice and the period preceding (n=652) 

By comparing the period during sex work practice and the period preceding, we saw a different picture (Table 2). More women had at least one pregnancy before sex work than they did during sex work in both countries (p-value <0>

Fewer women had resorted to therapeutic abortion in Mali than in Benin (14.9% vs 57.0%). In Benin, of the women who had at least one pregnancy, over half of the women had had a therapeutic abortion (59.9 %) during their lifetime and almost two out of three women who had a therapeutic abortion had more than one (64.4%) regardless of the period (data not shown). 

Depiction of pregnancy outcomes before and during sex work practice

In Mali, FSWs had a total of 470 pregnancies before sex work practice and 131 while practicing sex work (Table 3). Most of the pregnancies led to livebirths. Before sex work, it was three out of four (74.7%) and slightly more than one out of two during sex work (57.9%). Approximately the same proportion of pregnancies (13%) resulted in a therapeutic abortion both before and during sex work. Regarding pregnancies during the sex work period, most of them were from boyfriends (82.4%), and followed by husbands with 13.2%. Most of the pregnancies from husbands (90.5%) led to livebirths, with 9.5% of miscarriages. Finally, 14 Malian FSWs (8.8%) knew they were pregnant at the time of recruitment and 4 learned they were with the pregnancy test result.

* Women who learned that they were pregnant at the time of recruitment were not included in this tableTable 3: Pregnancy outcomes of female sex workers in Mali and Benin

In Benin, FSWs had a total of 1257 pregnancies before sex work and 235 while practicing sex work.  There was an important decrease in the livebirth rate from the period before sex work (60.6%) to that of sex work (17.6%). Expectedly, the therapeutic abortion rate markedly increased from 25.6% to 65.2

Discussion

The aim of this research was to describe the reproductive history of FSWs, a marginalized population, in both Mali and Benin. To acquire a global portrait of their realities, we described their reproductive history not only during sex work practice but also before. The main observation is that FSWs had more pregnancies leading to livebirths during the period preceding sex work practice. In Benin as in Mali, the incidence rate of pregnancy declined by half after the initiation of sex work. It is worthy to note that although fewer pregnancies occurred during sex work practice, the ones occurring during that period had lower livebirth rates and higher therapeutic abortion frequency, with associated complications such as hemorrhage and abdominal pain, as described by the FSWs we interviewed.

The number of pregnancies before sex work practice is undoubtedly high. The fact that a large number of pregnancies have occurred before sex work practice can lead women to precariousness and economical strain especially since the vast majority of these pregnancies led to livebirths. For example, in Benin, the country with the higher number of pregnancies before sex work practice, half of the women were widowed or separated. The lack of opportunities to earn money often draws women to sex work [13, 35]. In Mali, the women were 10 years younger than in Benin but were responsible, on average, for the same number of dependents (3.6). In Mali, family poverty is a determining factor for engaging in sex work. Young girls can be driven towards sex trade to help support their family [36]. In our population, one out of three Malian FSWs started selling sex before being 17 years old. 

When comparing the two countries, FSWs in Mali had twice less pregnancies during the period preceding sex work than in Benin. FSWs recruited in Mali were younger. Another factor that could explain this discrepancy is that FSWs in Benin were active sexually for a longer period before getting involved in sex work than women from Mali.  Indeed, FSWs had their first sexual relation on average over two years younger in Mali (15.2 years) compared to Benin (17.6 years), but the mean age at sex work initiation was 7 years younger in Mali (21.2 years) compared to Benin (28.2 years).  Consequently, women in Benin spent 10.6 of their sexually active years before selling sex rather than the six years found for Malian women.  For several women, the need to take care of their children is a sufficient incentive to engage in sex work practice [37-39]. In Mali, prior to initiating sex work, almost 60% had at least one child and in Benin, it was three out of four FSWs. 

The cumulative incidence of pregnancy during sex work is similar in the two countries with no regards to the outcome. Our findings indicate that a third of the FSWs had at least one pregnancy while practicing sex work. This overall cumulative incidence is high compared to what has been observed during sex work in other studies which is around 20% [27, 28, 40-43]. Social and popular judgements induce significant stigma to pregnant women during sex work practice [22]. The fact that our study inquired globally about reproductive history for their lifetime may have helped to reduce fear and shame surrounding those issues. The high frequency of pregnancies during sex work, compared to other studies, is worrisome especially considering that nursing a baby during sex work practice is undeniably an added burden for women who already are mothers [44].

 Fewer pregnancies occurred during sex work. but a smaller proportion of those led to livebirths. In Mali, three out of four pregnancies led to livebirths before sex work practice compared to half during sex work. In Benin, this difference was even greater, less than one out of five pregnancies have led to livebirths during sex work, as opposed to three out of five before. These data seem to support the idea that more pregnancies are unwanted during sex work practice. Nevertheless, it must be kept in mind that is not because a pregnancy’s outcome is a livebirth that the pregnancy is intended. Low-income countries have both the world’s highest unintended pregnancy rate and the world’s lowest proportion of unintended pregnancies ending in therapeutic abortion [45]. Worldwide, it is estimated that half of the unwanted pregnancies lead to therapeutic abortion but that the other half leads to livebirths [46].  In both countries, when the husband is the father, the livebirth rate is at its highest. Yet, those pregnancies represent less than 15% in each country. Most pregnancies during sex work came from boyfriends (82% in Mali and 65% in Benin). We also observed that condom use is low with their boyfriends compared to with their clients. Not using condoms with their boyfriends helps women to make a distinction between their professional and personal lives [47], but also seems to lead to unplanned pregnancies. Moreover, in Mali, the prevalence of miscarriage doubles between the two periods (9.4

Conclusions

Most of the pregnancies occurred before sex work practice in Mali as in Benin. Nevertheless, resorting to therapeutic abortion was more frequent during sex work practice especially for Beninese FSWs. These results highlight the need for two types of prevention. First, single mothers, as well as divorced and widowed ones, need to be supported to avoid sex work as a financial solution. Secondly, reproductive needs of FSWs must be acknowledged and understood so that specific sexual and reproductive health interventions can be targeted towards their needs. Finally, to properly support FSWs who want to have children, more research is needed to understand the mechanisms leading to the intention of becoming pregnant in this population.

Acknowledgements

The authors thank the study participants and the interviewers for their contribution to the study. They also acknowledge the contribution of the staff of the DIST in Benin, ARCAD-SIDA, SOUTARA and DANAYA-SO in Mali.

Conflict of Interest

The authors declare that they have no conflict of interest.

References

Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.

img

Virginia E. Koenig

Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.

img

Delcio G Silva Junior

Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.

img

Ziemlé Clément Méda

Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.

img

Mina Sherif Soliman Georgy

We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.

img

Layla Shojaie

The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.

img

Sing-yung Wu

Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.

img

Orlando Villarreal

Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.

img

Katarzyna Byczkowska

Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.

img

Anthony Kodzo-Grey Venyo

Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.

img

Pedro Marques Gomes

Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.

img

Bernard Terkimbi Utoo

This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.

img

Prof Sherif W Mansour

Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

img

Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

img

Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

img

Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

img

Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

img

Dr Suramya Dhamija

Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

img

Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

img

Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

img

Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

img

Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

img

Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

img

Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

img

Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

img

S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

img

Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

img

George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

img

Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

img

Khurram Arshad